Does your medical insurance have your best interest in mind?

In our physical therapy office, we see patients every day, who come in with serious pain and injuries, and they want the best in care for themselves. Our patients also pay a lot for their insurance and they want to be able to use what they’ve paid for. This makes complete sense and I would want to do the same thing. However, most are finding out that after paying so much every month for their insurance, they also have a high co-payment every time they see a doctor or a physical therapist. When coming to physical therapy, their co-pay is categorized as a specialist visit, which makes the visit more costly. The normal co-pay these days average $30 to $40 per visit, but we are seeing absurd co-pays of up to $60 – $75/ visit, which is higher than our cash based fee for service. Over the years, we’ve not only seen the insurance costs and co-pays go up, but the amount of documentation has significantly increased, inundating the clinicians to the point that it takes a lot of valuable time away from treating our patients.

When a patient comes in physical therapy, we perform an initial evaluation. We than send the clinical findings to the insurance company along with a recommendation for the number of visits needed to improve the patient’s signs and symptoms. Two or three days later, I may receive an authorization allowing us to begin treatment on the patient, but with a glitch. The insurance company will generally only authorize a fraction of the visits requested, which were originally based on the findings during the evaluation. I’ve discussed these cases with a representative at the insurance company; wait, I’m not actually talking to the insurance company, it’s a third party company hired by the insurance company to manage the authorizations. These companies are hired because they guarantee the insurance company that they can keep costs down, by aggressively managing the authorization of physical therapy visits. This makes their decisions financially based, not a decision based on medical necessity for that patient. Now, back to my story. The representatives tell me that the number of visits authorized is based off of the diagnosis code, not what is observed in the initial evaluation! This is how insurance companies can get in the way with the care needed by the patient.

Here’s a case scenario. A 45 year old male is doing house work and while on a ladder falls from a height of ten feet. He lands on the right side of his back causing a vertebral fracture and significant soft tissue trauma. The patient is complaining of 9/10 pain with light activity and 7/10 pain at rest or while lying down. He also complains of numbness and tingling down his right leg. His diagnosis code if for low back pain with radiculopathy. The representative at the third party company ties this diagnosis into a generalization for how many visits it should take to make the patient better and authorizes us 8 visits. After the 8 visits, the patient is feeling better, and rates his pain at 6-7/10 with light activity and a mild decrease in numbness, but can’t work because he’s an electrician and can’t perform the tasks that his job requires. So, he needs to continue physical therapy services to decrease his back pain, reduce muscle tone, improve vertebral range of motion, decrease the peripheral neural compression, and increase his flexibility. So, on re-submission for authorization, the insurance company states that they will give him 4 more visits, but that is it. No more PT will be authorized. After the four visits, the patient states that his pain is improving and that he’s moving better. He rates his pain at 5-6/10 and that his movement is at 50% of where it should be. He states that he’s not quite able to return to work. The insurance company has cut him off at this point, stating that he should be better by now. The patient however, decides that he’s going to continue with physical therapy until his pain level is tolerable. After 8 more visits, the patient reports that his pain is 1/10 with the absence of numbness, and that he’s returned to his job and is working without difficulty.

There is nothing more frustrating than this for patients living with pain that want to get help, or for the clinician who knows that they can help, but are limited by insurance coverage. We began offering continued care, for these situations, when the patient and referring physician agrees that continued treatment would be beneficial. We made this change because we found that we began changing our treatment approach in response to these healthcare insurance guidelines, but were becoming frustrated because we knew, and the patient knew, that this wasn’t what was best for the patient. We reached a point where we were filling out paperwork constantly, our patients would get denied, or their case is being reviewed for so long that the progress achieved would be lost.

I hope that our lawmakers will intervene, decreasing the cost of co-payments to no more than 20% of an agreed visit charge. For example, if the treatment charge were $60, than the patient would pay a $12 co-payment. I would also like to see that the number of visits authorized based on the clinical findings from our exam and assessment of the patient’s signs and symptoms, not a number based on a code!

In my opinion and other clinicians I’ve talked to, the high co-pay is a two-pronged strategy. First, it allows an employer’s healthcare coverage for their employees not to go up as much if they accept an increase in the employee’s co-payments. It also will limit the use of healthcare by the patient, because it is financially too high of a cost to seek treatment. By making these changes, it would make health care more reasonable and would allow the patient to base their decision on medical care from a needs perspective, not a financial constraint.

Dr. Gary Welch PT, CFCE, CFMT, CKTP, COMT

Owner – Spectrum Physical Therapy

100 Hospital Road, Suite 112

Patchogue, NY 11772

(631) 456-5512

Cell (631) 871-5652

Dr. Welch received his doctorate degree in physical therapy at Stony Brook University and is a Certified Functional Manual Therapist and Certified Orthopedic Manual Therapist. He is also certified in Job site analysis, functional capacity evaluations, and a kinesio taping practitioner. 2008 National Physical Therapists of the Year – Advance for Physical Therapist Magazine.